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Department of Reproductive Health and Research (RHR), World Health Organization

Managing Complications in Pregnancy and Childbirth

A guide for midwives and doctors 


Section 2 - Symptoms

Vaginal bleeding after childbirth

Vaginal bleeding in excess of 500 mL after childbirth is defined as postpartum haemorrhage (PPH). There are, however, some problems with this definition: 

  • Estimates of blood loss are notoriously low, often half the actual loss. Blood is mixed with amniotic fluid and sometimes with urine. It is dispersed on sponges, towels and linens, in buckets and on the floor.

  • The importance of a given volume of blood loss varies with the woman’s haemoglobin level. A woman with a normal haemoglobin level will tolerate blood loss that would be fatal for an anaemic woman.

Even healthy, non-anaemic women can have catastrophic blood loss. 

  • Bleeding may occur at a slow rate over several hours and the condition may not be recognized until the woman suddenly enters shock.

Risk assessment in the antenatal period does not effectively predict those women who will have PPH. Active management of the third stage should be practiced on all women in labour since it reduces the incidence of PPH due to uterine atony . All postpartum women must be closely monitored to determine those that have PPH.



  • Increased vaginal bleeding within the first 24 hours after childbirth (immediate PPH).

  • Increased vaginal bleeding following the first 24 hours after childbirth (delayed PPH).

Continuous slow bleeding or sudden bleeding is an emergency; intervene early and aggressively. 



  • SHOUT FOR HELP. Urgently mobilize all available personnel.

  • Make a rapid evaluation of the general condition of the woman including vital signs (pulse, blood pressure, respiration, temperature). 

  • If shock is suspected, immediately begin treatment. Even if signs of shock are not present, keep shock in mind as you evaluate the woman further because her status may worsen rapidly. If shock develops, it is important to begin treatment immediately.

  • Massage the uterus to expel blood and blood clots. Blood clots trapped in the uterus will inhibit effective uterine contractions.

  • Give oxytocin 10 units IM.

  • Start an IV infusion and infuse IV fluids.

  • Catheterize the bladder.

  • Check to see if the placenta has been expelled and examine the placenta to be certain it is complete (Table S-7). 

  • Examine the cervix, vagina and perineum for tears.

  • After bleeding is controlled (24 hours after bleeding stops), determine haemoglobin or haematocrit to check for anaemia:

- If haemoglobin is below 7 g/dL or haematocrit is below 20% (severe anaemia):

- Give ferrous sulfate or ferrous fumerate 120 mg by mouth PLUS folic acid 400 mcg by mouth once daily for 3 months;

- After 3 months, continue supplementation with ferrous sulfate or ferrous fumerate 60 mg by mouth PLUS folic acid 400 mcg by mouth once daily for 6 months.

- If haemoglobin is between 7–11 g/dL, give ferrous sulfate or ferrous fumerate 60 mg by mouth PLUS folic acid 400 mcg by mouth once daily for 6 months;

- Where hookworm is endemic (prevalence of 20% or more), give one of the following anthelmintic treatments:

- albendazole 400 mg by mouth once;

- OR mebendazole 500 mg by mouth once or 100 mg two times per day for 3 days; 

- OR levamisole 2.5 mg/kg body weight by mouth once daily for 3 days;

- OR pyrantel 10 mg/kg body weight by mouth once daily for 3 days.

- If hookworm is highly endemic (prevalence of 50% or more), repeat the anthelmintic treatment 12 weeks after the first dose.



Diagnosis of vaginal bleeding after childbirth 

Presenting Symptom and Other Symptoms and Signs Typically Present

Symptoms and Signs Sometimes Present

Probable Diagnosis

• Immediate PPHa

• Uterus soft and not contracted

• Shock

Atonic uterus

• Immediate PPHa


• Complete placenta

• Uterus contracted

Tears of cervix, vagina or perineum

• Placenta not delivered within 30 minutes after delivery

• Immediate PPHa

• Uterus contracted

Retained placenta

• Portion of maternal surface of placenta missing or torn membranes with vessels

• Immediate PPHa

• Uterus contracted

Retained placental fragments

• Uterine fundus not felt on abdominal palpation

• Slight or intense pain

• Inverted uterus apparent at vulva

• Immediate PPHb

Inverted uterus

• Bleeding occurs more than 24 hours after delivery

• Uterus softer and larger than expected for elapsed time since delivery

• Bleeding is variable (light or heavy, continuous or irregular) and foul-smelling

• Anaemia

Delayed PPH

• Immediate PPHa (bleeding is intra-abdominal and/or vaginal)

• Severe abdominal pain (may decrease after rupture)

• Shock

• Tender abdomen

• Rapid maternal pulse

Ruptured uterus

a Bleeding may be light if a clot blocks the cervix or if the woman is lying on her back.

b There may be no bleeding with complete inversion.




An atonic uterus fails to contract after delivery.

  • Continue to massage the uterus.

  • Use oxytocic drugs which can be given together or sequentially (Table S-8).


 Use of oxytocic drugs 



Ergometrine/ Methyl-ergometrine

15-methyl Prostaglandin F2α

Dose and route

IV: Infuse 20 units in 1 L IV fluids at 60 drops per minute 

IM: 10 units

IM or IV (slowly): 0.2 mg

IM: 0.25 mg

Continuing dose 

IV: Infuse 20 units in 1 L IV fluids at 40 drops per minute

Repeat 0.2 mg IM after 15 minutes

If required, give 0.2 mg IM or IV (slowly) every 4 hours 

0.25 mg every 15 minutes

Maximum dose

Not more than 3 L of IV fluids containing oxytocin

5 doses (Total 1.0 mg)

8 doses (Total 2 mg)


Do not give as an IV bolus

Pre-eclampsia, hypertension, heart disease



Prostaglandins should not be given intravenously. They may be fatal. 

- Check placenta again for completeness;

- If there are signs of retained placental fragments (absence of a portion of maternal surface or torn membranes with vessels), remove remaining placental tissue;

- Assess clotting status using a bedside clotting test.  Failure of a clot to form after 7 minutes or a soft clot that breaks down easily suggests coagulopathy.

  • If bleeding continues in spite of management above:

- Perform bimanual compression of the uterus (Fig S-4):

- Wearing high-level disinfected gloves, insert a hand into the vagina and form a fist;

- Place the fist into the anterior fornix and apply pressure against the anterior wall of the uterus;

- With the other hand, press deeply into the abdomen behind the uterus, applying pressure against the posterior wall of the uterus;

- Maintain compression until bleeding is controlled and the uterus contracts.

Figure S-4

 Bimanual compression of the uterus 


- Alternatively, compress the aorta (Fig S-5): 

- Apply downward pressure with a closed fist over the abdominal aorta directly through the abdominal wall:

- The point of compression is just above the umbilicus and slightly to the left;

- Aortic pulsations can be felt easily through the anterior abdominal wall in the immediate postpartum period. 

- With the other hand, palpate the femoral pulse to check the adequacy of compression:

- If the pulse is palpable during compression, the pressure exerted by the fist is inadequate; 

- If the femoral pulse is not palpable, the pressure exerted is adequate;

- Maintain compression until bleeding is controlled.

Figure S-5

Compression of abdominal aorta and palpation of femoral pulse 

Packing the uterus is ineffective and wastes precious time. 

  • If bleeding continues in spite of compression:

- Perform uterine and utero-ovarian artery ligation;

- If life-threatening bleeding continues after ligation, perform subtotal hysterectomy.


Tears of the birth canal are the second most frequent cause of PPH. Tears may coexist with atonic uterus. Postpartum bleeding with a contracted uterus is usually due to a cervical or vaginal tear.


There may be no bleeding with retained placenta. 

  • If you can see the placenta, ask the woman to push it out. If you can feel the placenta in the vagina, remove it.

  • Ensure that the bladder is empty. Catheterize the bladder, if necessary.

  • If the placenta is not expelled, give oxytocin 10 units IM if not already done for active management of the third stage.

Do not give ergometrine because it causes tonic uterine contraction, which may delay expulsion. 

Note: Avoid forceful cord traction and fundal pressure as they may cause uterine inversion.

Note: Very adherent tissue may be placenta accreta. Efforts to extract a placenta that does not separate easily may result in heavy bleeding or uterine perforation which usually requires hysterectomy. 



There may be no bleeding with retained placental fragments. 

When a portion of the placenta—one or more lobes—is retained, it prevents the uterus from contracting effectively. 

  • Feel inside the uterus for placental fragments. Manual exploration of the uterus is similar to the technique described for removal of the retained placenta.

  • Remove placental fragments by hand, ovum forceps or large curette.

Note: Very adherent tissue may be placenta accreta. Efforts to extract fragments that do not separate easily may result in heavy bleeding or uterine perforation which usually requires hysterectomy. 

  • If bleeding continues, assess clotting status using a bedside clotting test. Failure of a clot to form after 7 minutes or a soft clot that breaks down easily suggests coagulopathy.


The uterus is said to be inverted if it turns inside-out during delivery of the placenta. Repositioning the uterus should be performed immediately. With the passage of time the constricting ring around the inverted uterus becomes more rigid and the uterus more engorged with blood.

  • If the woman is in severe pain, give pethidine 1 mg/kg body weight (but not more than 100 mg) IM or IV slowly or give morphine 0.1 mg/kg body weight IM.

Note: Do not give oxytocic drugs until the inversion is corrected.

- ampicillin 2 g IV PLUS metronidazole 500 mg IV;

- OR cefazolin 1 g IV PLUS metronidazole 500 mg IV.

  • If there are signs of infection (fever, foul-smelling vaginal discharge), give antibiotics as for metritis.

  • If necrosis is suspected, perform vaginal hysterectomy. This may require referral to a tertiary care centre.


Prolonged or delayed PPH may be a sign of metritis. 

Top of page


Clinical principles

Rapid initial assessment

Talking with women and their families

Emotional and psychological support


General care principles

Clinical use of blood, blood products and replacement fluids

Antibiotic therapy

Anaesthesia and analgesia

Operative care principles

Normal Labour and childbirth

Newborn care principles

Provider and community linkages



Vaginal bleeding in early pregnancy

Vaginal bleeding in later pregnancy and labour

Vaginal bleeding after childbirth

Headache, blurred vision, convulsions or loss of consciousness, elevated blood pressure

Unsatisfactory progress of Labour

Malpositions and malpresentations

Shoulder dystocia

Labour with an overdistended uterus

Labour with a scarred uterus

Fetal distress in Labour

Prolapsed cord

Fever during pregnancy and labour

Fever after childbirth

Abdominal pain in early pregnancy

Abdominal pain in later pregnancy and after childbirth

Difficulty in breathing

Loss of fetal movements

Prelabour rupture of membranes

Immediate newborn conditions or problems


Paracervical block

Pudendal block

Local anaesthesia for caesaran section

Spinal (subarachnoid) anaesthesia


External version

Induction and augmentation of labour

Vacuum extraction

Forceps delivery

Caesarean section


Craniotomy and craniocentesis

Dilatation and curettage

Manual vacuum aspiration

Culdocentesis and colpotomy


Manual removal of placenta

Repair of cervical tears

Repair of vaginal and perinetal tears

Correcting uterine inversion

Repair of ruptured uterus

Uterine and utero-ovarian artery ligation

Postpartum hysterectomy

Salpingectomy for ectopic pregnancuy



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